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Research Article | DOI: https://doi.org/10.31579/2637-8892/166
1Clinical Psychologist and Research Scholar In Psychology,Gurukul Kangari University, Haridwar,Uttarakhand.
2Assistant Professor, Department of Psychology, Jamia Millia Islamia,New Delhi
3Assistant Professor, Department of Psychology, Gurukul Kangari University, Haridwar, Uttarakhand
*Corresponding Author: Noor Shabina, Clinical Psychologist and Research Scholar In Psychology (Gurukul Kangari University, Haridwar,Uttarakhand)
Citation: Shabina N., Abid H. Zaidi, Rani S. (2022) Effectiveness of Cognitive Behavioural Therapy on the Single Case Study Obsessive Compulsive Disorder.J. Psychology and Mental Health Care, 6(4): DOI: 10.31579/2637-8892/166
Copyright: © 2022, Noor Shabina, This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Received: 09 March 2022 | Accepted: 13 April 2022 | Published: 07 May 2022
Keywords: obsessive compulsive disorder; anxiety; depression; cognitive behavioral therapy; jacobson’s progressive muscular relaxation
This study is a single case therapeutic intervention based report; we have to design pre and post assessment with the help of some psychological rating tools. The present study examined to the effectiveness of cognitive behavioral and some techniques used of same therapeutic relational approaches, this is a pure or predominant obsession is a subtype of obsessive compulsive disorder case according to (ICD-11 under the categories “Obsessive Compulsive Disorder with fair to good Insight, 6B20.0. Depressive Disorder, GA 34.41. Generalized Anxiety Disorder, 6B00”). This study used based of cognitive behavior, CBT Model, ERP and used multiple therapeutic techniques of Cognitive behavioral therapy. The present study W, 23 yrs old married male came with chief complaints of the multiple blasphemous thoughts, unwanted sexual images running in the mind, unseen images of sexual area of mother and God since 12 years and seen multiple symptoms of the generalized anxiety or depressive psychopathology. Studying in graduation and belong to middle SES according to kuppuswamy scale. He brought by his parents in IMHH, Agra in OPD and done pre assessment before the applied therapy session. His result showed high severity of OCD symptoms. After 3 months again applied same tools, and seen approximately 50% to 55% major reduction his symptoms that further gradually decreased his symptoms and sessions continued till 2 months. Follow-up continued and patient no longer meet the criteria for OCD, Generalized Anxiety disorders and Depressive symptoms.
OCD is currently considered to be one of the five most prominent psychiatric disorders according to ICD-11. OCD characterized by the presence of obsessions is a multiple types of Obsessive compulsive thoughts which affects approximately1-3% with lifetime prevalence and leading the cause symptoms of other psychiatric illness (Reddy et al., 2017). Cognitive behavior therapy (CBT) involving exposure and response prevention is the high standard for the base of 3rd generation of psychotherapeutic intervention for obsessive-compulsive disorder (OCD). And twenty-seven patients with Diagnostic and Statistical Manual of Mental Disorders. Fourth Edition diagnosis of OCD. Overall integrated the findings indicating of the 27 patients, 18 (67%) achieved remission (55% reduction in the YBOCS severity score) at 3-month follow-up of the OCD population categories. (Kumar et al., 2016). Conducted other dimensions of obsessive-compulsive disorder (OCD) is a leading cause of mental or behavioral disorder emergencies with Mind with Body Reaction. Sexual obsessions are perhaps the least understood manifestation of OCD. Common themes include obsessions about sexual orientation, infidelity, sexual deviations, incest, pregnancy, and blasphemous thoughts combining religion and sex and This book describes new techniques for addressing sexual-OCD (S-OCD) using the cognitive sematic association splitting techniques and helps towards the multiple Obsessive-Compulsive Disturbances. ( APA., 2021). In this literature showed that the having the difficulty related neurotic disturbances and seen multiple Obsessive-Compulsive symptoms and presented multiple anxiety traits with depressive disorder with solved the case of primary symptoms then secondary multiple other active psychopathology. CBT is the helps of primary symptoms then reduced gradually other symptoms.
Index patient was functioning well apparently 12 years back when he fell from a height of 8 ft and had a back injury followed which he started complaining of headache. This continued for many years. At about 13 years of age he started engaging in various philosophical thoughts like- “who made Allah, how his face looks like?” Subsequently by 16 years of age, he started masturbating and the act used to often be guilt provoking. Few years later, he started getting involved in a relationship which was unacceptable by family members and since he broke his promise with the girl, he started remaining tensed most times of the day, until one day while sleeping he had thought of having sex with God (Hazrate Fatima). This created a state of intense guilt, anxiety shame and self-blame for which he apologized to God many times. He tried to resist but was unable to do it and started remaining preoccupied with such thoughts. Subsequently, he also started having sexual thoughts for his mother, father and even his own child. In 2010, he got married, after 5 years of marriage he started having images of female vagina. Later, he also started having images of various other sexual organs of female like breast, buttocks etc. However, he remains preoccupied with thought and image of vagina so much that his activities of daily living were hampered such that it become s very difficult to make a decision while sitting or standing as he fears that he will kill Allah or will have sex with his mother if he performs certain acts. Since last 1 year he has also started controlling his thoughts by either replacing image with less threatening image or saying a mental prayer or just avoiding the activities he faces difficulties in performing.
His persistent and pervasive mood has been anxious and irritable. He has difficulty carrying out activates of daily living because of the preoccupation with these thoughts and images.
On M.S.E. patient was kempt and tidy, in touch with surrounding, eye contact maintained and had a cooperative attitude. His affect was anxious or depressed with normal range and reactivity. In thought possession he reports obsessive thought, increased suicidal wishing and images about sex and aggression as well as checking compulsions. Psychomotor activity was increased during interview time. No abnormality could be elicited in perception with intact judgment and grade IV insight.
Diagnostic Formulation:-
Index Patient X, 23 yrs old unmarried male, studying in graduation, belongs to urban background of Agra. The chief complaints were blasphemous thoughts, Seeing images of sexual area of mother and God, Violent and aggressive thoughts and images, checking doors and taps repeatedly and excessive concern with moral fears Since 4 years.The significant findings in MSE indicating obsessions and compulsions, sad mood, insight is grade IV. History and MSE finding suggests that patient is provisionally diagnosed with ICD-11 “(Obsessive Compulsive Disorder with fair to good Insight, 6B20.0. Depressive Disorder, GA 34.41. Generalized Anxiety Disorder, 6B00)”.
Psychotherapeutic Formulation:-
He is a member of a joint family, living with his wife, children, parents and brothers. He is a nominal head and his father is a functional head of the family. His family environment is strained because of her obsessive and compulsive behavior. But his primary and secondary support system is good.
Pre Assessment for Psychotherapy:-
Impression
Raw Score= 31 (Severe Range of Obsessive Compulsive Symptoms)
Model of Therapy:
Goals or the Therapy:
Short term goals :
Long terms goals:
Cognitive behavior therapy for obsessive thoughts.
Techniques Used
Psychoeduaction
Cognitive bio-behavioral self treatment
Relabel
Re-attribute
For obsessive ruminations
For depressive symptoms
Duration of sessions: 40-50 minutes, period or total time duration: 6 months to 8 months
Number of sessions: 35 to 40 sessions.
Detailed history was taken from patient. Conversation was carried out to build therapeutic alliance. Detailed psycho-education was given to the patient which included:
MIDDLE PHASE:
Middle phase of the therapy was divided into two phases:
PHASE I:
In the first phase, the focus was on introducing various cognitive techniques to reduce the self-blame and to initiate a process of challenging over-beliefs and mis-interpretations associated with OCD. This was done in following way:
Phase II:
The next phase of therapy began with a elaborate discussion on the rationale of using ERP (exposure and response prevention) which basically targets the anxiety relieving ability that safety seeking behavior or compulsions produces is very short lived and counter-productive. And as proposed, each of these ERP sessions were followed by various cognitive techniques mentioned in phase I to enhance understanding. For the purpose, Anxiety graph was made and explained to the patient and discussed about rating of subjective unit of distress (SUDS). Then the patient was asked to tell about the anxiety provoking situation & thereafter asked to provide the associated SUDS with each of the situation on 0-100 point visual analogue scale.
In this phase, brief conversation was carried out about previously discussed matters. Then the patient was exposed to least anxiety provoking situation i.e. putting his hands in the pocket. Before the start of the session therapist did the task to show the patient that it was doable after that patient was made to do it. In this sessions patient was very much distressed & anxious though this task was least anxiety provoking for him. He gave discomfort rating that was started with 35 & then gradually increases to 80 then decreases to 15. The duration of her distress was 1 hour 15 minutes after the exposure he was prevented from engaging in the neutralizing behaviour i.e. compulsive saying of mental prayer. Immediately after the ERP session, revision of various cognitive techniques discussed previously, were introduced again in order to help patient understand the irrationality of thought. This subsequently helps in challenging the dysfunctional assumption and distortion to generate alternative explanations for the problem behavior. The technique of reattribution was again highlighted to make him understand that it the “OCD Brain” thought rather than his personal responsibility. He was asked to practice all these session at home also. Same task was practiced for another sessions. After the 3rd session his distress score was 50. In the 5th session hiss distress score was 25. His distress was decreased within 30 minutes & also prevented from compulsive behavior. In this way patient were exposed to least anxiety provoking situation to the most anxiety situation one by one manner.. Remaining sessions of this phase of treatment will be spent exclusively for ERP. This phase will last for approximately 10 more sessions till he was exposed and subsequently habituated to highest anxiety provoking activities.
Phase III:
Termination Phase:
All previous session were revised. He was able to perform the task well. He was performing all of these with a mild degree of subjective anxiety, & without the following compulsive acts or if performed, within acceptable limits. A health perspective over his illness was also generated which could tackle both his obsessive ruminations and resulting depressive symptoms. Thus, the session was terminated. Patient was then asked to come for booster session.
Post-Therapy Assessment:
At the end of the final session all previously used tools were re-administered to monitor progress or client on Y-BOCS, there was a score of 19 indicating moderate range of obsessive compulsive symptoms. On BDI, OARS and HAM-D, there was mild depression indicated by score of 11 and 12 respectively. On OARS, a score of 16 was obtained indicating mild range of anxiety symptoms. The improvement obtained can be graphically depicted like this:
Anxiety hierarchy was re-plotted to see the difference between the SUDS rating after therapy and the scores obtained are as follows:
Index patient’s problem of blasphemous thoughts, Seeing images of sexual area of mother and God, Violent and aggressive thoughts and images, checking doors and taps repeatedly and excessive concern with moral fears was improved with therapy. Now patient is able manage himself and able to facing any situation.
The current study understand the OCD, especially sexual obsession towards the own members of the family, this is very stressful situation sometime happened. First of all understand the symptoms and elicited the situation. CBT or JPMR is the best combination of this treatment for the helps of reduced the active psychopathology. Cognitive bio-behavioral self treatment (Schwartz, 1996): Since patient has less knowledge about his illness, he has inflated sense of responsibility and self-blaming towards causing his own illness and hence always remains guilt prone. Thus, these techniques would target at his attribution style which will facilitate better adherence to standard CBT approach. Behavioral technique (ERP): Though ERP has been more standardized for overt compulsive behavior, in the present module patient presents with various covert compulsions. Moreover, Religious patients suffering from blasphemous thoughts often refuse ERP, since they experience such instructions sinful. However, Evidences supporting its efficacy (Abramowitz et al., 2002) proposes that if cognitive techniques immediately follow ERP sessions, especially with mental compulsions, behavior therapy can lead to successful outcome (Gordon 2005; et al., 1992). Cognitive Therapy: It has been suggested as standard treatment approach for altering both strongly held beliefs associated with OCD symptoms and interpretations of intrusive mental experiences change responsibility beliefs and appraisals and thereby to reduce distress and eliminate neutralizing responses, which usually occurred as covert neutralizing (mental) rituals (Rachman & Hodgson, 1980; Salkovskis, 1998).
Urgent care: